Supplementary Material for: Outcome and Safety of Unplanned-Start Peritoneal Dialysis according to Break-In Periods: A Systematic Review and Meta-Analysis

Introduction: The best timing of peritoneal dialysis (PD) initiation after catheter implantation is still controversial. It is necessary to explore whether there exists a waiting period to minimize the risk of complications. Methods: A systematic review and meta-analysis were searched in multiple electronic databases published from inception to February 29, 2020, to identify cohort studies for evaluating the outcome and safety of unplanned-start PD (<14 days after catheter insertion). Risks of bias across studies were evaluated using Newcastle-Ottawa Quality Assessment Scale. Results: Fourteen cohort studies with a total of 2,401 patients were enrolled. We found that early-start PD was associated with higher prevalence of leaks (RR: 2.67, 95% CI, 1.55–4.61) and omental wrap (RR: 3.28, 95% CI, 1.14–9.39). Furthermore, patients of unplanned-start PD in APD group have higher risk of leaks, while those in CAPD group have a higher risk of leaks, omental wrap, and catheter malposition. In shorter break-in period (BI) group, the risk of suffering from catheter obstruction and malposition was higher for patients who started dialysis within 7 days after the surgery than for patients within 7–14 days. No significant differences were found in peritonitis (RR: 1.00; 95% CI, 0.78–1.27) and exit-site infections (RR: 1.12; 95% CI, 0.72–1.75). However, shorter BI was associated with higher risk of mortality and transition to hemodialysis (HD) while worsen early technical survival, with pooled RR of 2.14 (95% CI, 1.52–3.02), 1.42 (95% CI, 1.09–1.85) and 0.95 (95% CI, 0.92–0.99), respectively. Conclusions: Evidence suggests that patients receiving unplanned-start PD may have higher risks of mechanical complications, transition to HD, and even mortality rate while worsening early technical survival, which may not be associated with infectious complications. Rigorous studies are required to be performed.

引言：导管植入术后启动腹膜透析（Peritoneal Dialysis, PD）的最佳时机仍存在争议，有必要探索是否存在一段等待期以最小化并发症风险。
方法：本研究通过检索多个电子数据库自建库至2020年2月29日发表的文献，开展系统评价与荟萃分析，纳入用于评估导管置入后14天内启动的计划外腹膜透析（unplanned-start PD）的结局与安全性的队列研究。采用纽卡斯尔-渥太华质量评估量表（Newcastle-Ottawa Quality Assessment Scale）评估各研究的偏倚风险。
结果：最终纳入14项队列研究，共计2401例患者。研究发现，早期启动腹膜透析与更高的渗漏（相对风险RR: 2.67, 95%置信区间CI: 1.55–4.61）及大网膜包裹（RR: 3.28, 95%CI: 1.14–9.39）患病率相关。进一步分析显示，自动化腹膜透析（Automated Peritoneal Dialysis, APD）组的计划外启动腹膜透析患者渗漏风险更高，而持续性不卧床腹膜透析（Continuous Ambulatory Peritoneal Dialysis, CAPD）组患者则存在更高的渗漏、大网膜包裹及导管错位风险。在更短的透析诱导期（Break-in Period, BI）组中，术后7天内启动透析的患者相较于7~14天启动者，发生导管阻塞及错位的风险更高。两组在腹膜炎（RR: 1.00; 95%CI: 0.78–1.27）及出口部位感染（RR: 1.12; 95%CI: 0.72–1.75）方面无显著差异。然而，更短的诱导期与更高的死亡风险、转为血液透析（Hemodialysis, HD）风险相关，同时会降低早期技术生存率，合并相对风险分别为2.14（95%CI: 1.52–3.02）、1.42（95%CI: 1.09–1.85）及0.95（95%CI: 0.92–0.99）。
结论：现有证据表明，接受计划外启动腹膜透析的患者可能面临更高的机械性并发症、转为血液透析甚至死亡的风险，同时早期技术生存率下降，且该关联与感染性并发症无关，仍需开展严谨的高质量研究。